Bowel Dysfunction and Management

General Bowel Management Systematic Review

Discussion

Two relevant systematic reviews were found. Krassioukov et al. (2010) reviewed all research literature published from 1950 to July 2009 related to neurogenic bowel management in individuals with SCI. They reported that although multifaceted bowel management programs are commonly used, only lower levels of evidence support these programs. Coggrave et al. (2014) found 20 randomized or quasi-randomized trials published up to June 2012. There was evidence that the duration of bowel care could be significantly reduced through use of drugs and electrical stimulation, and that transanal irrigation improved a range of outcomes. Both reviews noted that there is a need for more high quality research in the field of bowel management for SCI patients. Future trials should include evaluation of the “acceptability of the intervention to patients and the effect on their quality of life”.

Table 2. General Bowel Management Systematic Review

Authors; Country Date included in the review Total Sample Size Score	Methods Databases Level of Evidence	Conclusions
Coggrave et al., 2014; UK Published articles up to June 2012 N=20 AMSTAR: 9	Methods: Literature search for randomized and quasi-randomized studies evaluating any type of intervention for management of fecal incontinence and constipation in people with central neurological disease or injury. Only SCI findings are reported. Databases: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE In-Process, CINAHL, search of relevant journals and conference proceedings.	1. Small trials demonstrated statistically significant improvement in total bowel care time comparing: – intramuscular neostigmine-glycopyrrolate and placebo (mean difference (MD) = 23.3 min) – bisacodyl in polyethylene glycol suppository (43 min) compared with bisacodyl in vegetable oil suppository (74.5 min) and – use of an abdominal electrical stimulation belt vs no stimulation (MD= 29.3 min).2. One trial showed transanal irrigation significantly improved a range of outcomes compared to conservative management. There was higher patient satisfaction with this method.3. Three trials of cisapride were withdrawn from the review as the drug is no longer available.
Krassioukov et al., 2010; Canada Published articles from 1950 to July 2009 N= 57 AMSTAR: 5	Methods: Literature search for randomized-controlled trials (RCTs), prospective cohort, case–control, pre–post studies, and case reports assessing pharmacological and non-pharmacological interventions for management of neurogenic bowel after SCI. PEDRo Scale was used to grade RCTs (0-11). Modified Downs and Black scale was used to grade non RCTs (0 to 28). Databases: PubMed/MEDLINE, CINAHL, EMBASE, PsycINFO.	1. Multifaceted bowel management programs are the first approach to neurogenic bowel programs and are supported by lower-level evidence (3 pre–post studies, level 4). 2. More than one intervention is usually necessary for individuals to develop an effective bowel routine (e.g. digital rectal stimulation with diet and fluid intake). 3. Evidence is low for non-pharmacological approaches and high for pharmacological interventions. 4. Diet and fluid intake are important components of multifaceted bowel management programs. 5. Transanal irrigation is a promising technique to reduce constipation and fecal incontinence 6. Colostomy is a safe, effective method of managing severe and chronic GI problems, and assist with treating perianal pressure ulcers in persons with SCI.

Authors; Country

Date included in the review

Total Sample Size

Score

Methods

Databases

Level of Evidence

Conclusions

Coggrave et al., 2014; UK

Published articles up to June 2012

N=20

AMSTAR: 9

Methods: Literature search for randomized and quasi-randomized studies evaluating any type of intervention for management of fecal incontinence and constipation in people with central neurological disease or injury. Only SCI findings are reported.

Databases: Cochrane Central

Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE

In-Process, CINAHL, search of relevant journals and conference proceedings.

1. Small trials demonstrated statistically significant improvement in total bowel care time comparing:
– intramuscular neostigmine-glycopyrrolate and placebo (mean difference (MD) = 23.3 min)
– bisacodyl in polyethylene glycol suppository (43 min) compared with bisacodyl in vegetable oil suppository (74.5 min) and
– use of an abdominal electrical stimulation belt vs no stimulation (MD= 29.3 min).2. One trial showed transanal irrigation significantly improved a range of outcomes compared to conservative management. There was higher patient satisfaction with this method.3. Three trials of cisapride were withdrawn from the review as the drug is no longer available.

Krassioukov et al., 2010; Canada

Published articles from 1950 to July 2009

N= 57

AMSTAR: 5

Methods: Literature search for randomized-controlled trials (RCTs), prospective cohort, case–control, pre–post studies, and case reports assessing pharmacological and non-pharmacological interventions for management of neurogenic bowel after SCI. PEDRo Scale was used to grade RCTs (0-11).

Modified Downs and Black scale was used to grade non RCTs (0 to 28).

Databases: PubMed/MEDLINE, CINAHL, EMBASE, PsycINFO.

1. Multifaceted bowel management programs are the first approach to neurogenic bowel programs and are supported by lower-level evidence (3 pre–post studies, level 4).

2. More than one intervention is usually necessary for individuals to develop an effective bowel routine (e.g. digital rectal stimulation with diet and fluid intake).

3. Evidence is low for non-pharmacological approaches and high for pharmacological interventions.

4. Diet and fluid intake are important components of multifaceted bowel management programs.

5. Transanal irrigation is a promising technique to reduce constipation and fecal incontinence

6. Colostomy is a safe, effective method of managing severe and chronic GI problems, and assist with treating perianal pressure ulcers in persons with SCI.

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